Large-volume IM Injections: A Review Of Best Practices
feature Large-volume IM injectionsLarge-volume IM injections:A review of best practicesIntramuscular injections offer improved treatment adherence, ease inmonitoring of adverse effects, and multiple administration sitesUna Hopkins, RN, FNP-BC, DNP;Claudia Y. Arias, RN, OCN michele grahamDorsogluteal siteFIGURE 1A. Potential sites for intramuscular injection: Dorsogluteal siteIntramuscular (IM) injection is one of manyroutes for administering medications, including antibiotics, vaccines, hormonal therapies,and corticosteroids.1,2 Even when alternate routesof administration are available, IM injectionsmay be preferred when a patient cannot tolerateoral medication or when adherence is a concern.2IM injections also may be beneficial for absorption compared with other routes of administration (ie, faster than subcutaneous injection andslower than intravenous administration). Inaddition, some medications contain componentsthat can irritate subcutaneous tissue but notmuscle tissue, which also can tolerate larger fluidvolumes with minimal discomfort.3,4Large-volume injections (3 mL or greater),however, are not frequently administered; andmany clinicians may not be familiar with theirappropriate use, possible side effects, and potentialefficacy. Medications administered via largevolume IM injections include ceftazidime (Fortaz,Tazicef, generics), cefuroxime (Ceftin, Zinacef,generics), ertapenem (Invanz), penicillin G benzathine (Bicillin L-A, Permapen), and fulvestrant(Faslodex).5-9 This article discusses the practicalissues related to administration of large-volumeIM injections, in the setting of administeringfulvestrant for the treatment of breast cancer, witha focus on best practices for efficacy and safety.IM injections are administered in five potentialsites: deltoid (commonly used for adult vaccinations), dorsogluteal, ventrogluteal, rectus32 oncology nurse advisor january/february 2013 www.OncologyNurseAdvisor.com
femoris, and vastus lateralis3,10,11 (Figure 1). Maximum volumes have been proposed across the various IM sites foradult patients3,12-16 ( Table 1). Overall, 5 mL has been citedfor adults as the maximum volume for a single IM injection,with lower maximums proposed for adult patients with lessdeveloped or small muscle mass.3,13,14INTRAMUSCULAR INJECTIONSOnce administered exclusively by physicians, IM injectionsbecame a primary-nurse responsibility during the 1960s.1However, few evidence-based guidelines for IM injectionsare available, and discrepancies within nursing textbookshave been noted.10-13 In addition, current guidelines do notaddress administration of large-volume injections.The dorsogluteal site for IM injections is the one nurseshave the most experience using, as this is what is traditionally taught in nursing schools and covered in nursingtextbooks.16-18 A recent study found that acute care nurses inCanada preferentially selected the dorsogluteal IM injectionsite over the ventrogluteal IM injection site.19 The majority of respondents cited their own level of comfort as thepredominant reason for this preference. However, nurseswho were older than 30 years, were diploma prepared, andhad more than 4 years of nursing experience were morelikely to choose the dorsogluteal site; whereas nurses whowere age 20 to 24 years, were degree prepared, and had 1to 4 years of nursing experience were more like to choosethe ventrogluteal site.19 This finding supports the idea thatDeltoid sitethe ventrogluteal site may be used more often by those whoreceived specific guidance in administering at that site.The ventrogluteal region (targeting the gluteus medius1,16)and the vastus lateralis region are free of major nerves andblood vessels.3,17,18 The safety of the ventrogluteal region asan area for administering IM injections is established andthe area is identified as a preferred site within clinical practice guidelines.1,3,12,16-18,20 Nevertheless, nurses are reluctantto use this site, possibly because of a lack of confidence inidentifying the area or the absence of recommendations bynursing authors or within nursing education.17,18,20,21 Theventrogluteal site is identifiable by a prominent and easilypalpable bony landmark; however, it is a small area, whichmay be an issue in the setting of repeated injections.17,18Inexperience with injection techniques and inaccuratelandmarking can result in injection-site pain or injury.18,22Sciatic nerve pain can occur, though rarely, if a dorsoglutealinjection is given too low.20,23-25 This risk can be attenuated byselecting the upper and outer quadrant of the buttock.3,10 Boththe sciatic nerve and the superior gluteal artery are only a fewcentimeters from this site so care should be taken to landmarkthe injection accurately.22 Other injection-related side effectsare granuloma; intravascular injection; muscle fibrosis andcontracture; tissue necrosis; hematoma; abscess; cellulitis; andinjury to blood vessels, bone, and peripheral nerves.3,18In a small study conducted by Boyd and colleagues atMD Anderson Cancer Center in Houston, Texas, 146 of251 intended gluteal IM injections (58%) administered byVentrogluteal siteVastuslateralis siteBCDFIGURE 1b, c, d. Potential sites for intramuscular injection: Deltoid, ventrogluteal, rectus femoris, and vastus lateralis siteswww.OncologyNurseAdvisor.com january/february 2013 oncology nurse advisor 33 michele grahamRectusfemoris site
feature Large-volume IM injectionsnurses were deemed successful by pelvic CT scan, while 105(42%) were associated with subcutaneous nodules, indicatingsubcutaneous placement. Successful IM injection was associated with self-reported indicators of nursing experience,injection-site location method, depth of needle insertion, anduse of nonsyringe hand. Common reasons for unsuccessfulIM injection included poor injection-site selection and notadvancing the needle to full length. It was estimated thatneedles 38 mm (1.5 inches) or more would be needed forsuccessful IM injection in 14% to 34% of patients.26IN THE SETTING OF HR METASTATIC BREAST CANCERFulvestrant, an estrogen receptor antagonist, is indicated forthe treatment of hormone receptor-positive (HR ) metastaticbreast cancer in postmenopausal women who have failedantiestrogen therapy.9 It is administered as a once-monthlyIM injection with a 21-gauge, 1.5 inch (40 mm) needle.Oral therapies (eg, tamoxifen [Soltamox, generics] and aromatase inhibitors) are also routinely used for this indication.However, despite the assumed convenience of oral therapy,nonadherence or suboptimal adherence is a significantissue with this modality. Poor adherence to tamoxifen, forexample, has a significant association with increased risk ofdeath from breast cancer.27A 2006 survey of patients with breast cancer conductedby the Sussex Psychosocial Oncology Group revealed aninitial preference for oral endocrine medications.28 However,almost 50% of respondents admitted to inconsistent adherence to current oral therapies, and patients’ perception oftherapy safety and efficacy was more important than route ofadministration.28 IM fulvestrant may be beneficial from anadherence standpoint because it is administered in a clinicalsetting; moreover, the controlled setting offers the opportunity for closer monitoring of adverse events.27,29Fulvestrant was initially approved in the United States in2002 as a 250-mg monthly dose (ie, one 5-mL injectionor two concurrent 2.5-mL injections [50 mg/mL]). Thepossibility of developing more concentrated formulationsof fulvestrant, which would theoretically allow for loweroverall injection volumes, has been investigated. Due tothe solubility of the active drug, the maximum concentration formulated to date is 250 mg per 5 mL (50 mg/mL).30In pivotal clinical studies of fulvestrant 250 mg/month,ON THEWEBTHERE’S MORE OF THIS ARTICLE ONLINE!Go to OncologyNurseAdvisor.com/injections to see this article with additional tables.injection-site reactions occurred in 1% of treatment coursesor 7% of patients treated with one 5-mL injection and in4.6% of treatment courses or 27% of patients treated withtwo 2.5-mL injections.9,31 No sciatic nerve injuries havebeen reported in the literature for fulvestrant.The fulvestrant dose approved by the US Food and DrugAdministration was increased to 500 mg/month (two 5-mLinjections) based on results from the Comparison of Faslodexin Recurrent or Metastatic Breast Cancer (CONFIRM) trial.30The CONFIRM trial found that 500 mg/month fulvestrantsignificantly prolonged progression-free survival versus 250 mg/month fulvestrant without increasing toxicity.30 The 500-mg/month dose is administered as two 5-mL IM injections (250mg/5 mL each), one in each buttock, on days 1, 15, and 29, andonce monthly thereafter.9 The additional dose of fulvestrant,given 2 weeks after the initial dose, allows steady-state bloodlevels to be reached within the first month of treatment.9CLINICAL TRIALS SUPPORT LARGER DOSERobertson and colleagues combined and evaluated data fromtwo trials of fulvestrant (250 mg monthly) versus anastrozoleoral tablets (1 mg/day) for advanced breast cancer pretreatedwith endocrine therapy.31 Trial 0020 was an open-label studyin which fulvestrant was administered as a single 5-mL IMinjection. Trial 0021 was a double-blind, placebo-controlledstudy with fulvestrant administered as two 2.5-mL injections; anastrozole-treated patients in Trial 0021 received twoplacebo injections. The frequency of injection-site reactionsappeared similar in both groups in Trial 0021 (4.6% forfulvestrant and 4.4% for placebo groups).31FINDER 1 (Faslodex Investigation of Dose Evaluation inEstrogen Receptor-Positive Advanced Breast Cancer) andFINDER 2 (Faslodex Investigation of Dose Evaluation inEstrogen Receptor-Positive Advanced Breast Cancer 2) weredesigned to evaluate the efficacy and safety of three dosingregimens of fulvestrant: 250 mg/month (ie, every 28 days),the loading dose (LD; 500 mg on day 0 and 250 mg on days14 and 28 of month 1, and 250 mg every 28 days thereafter),and 500 mg/month (on days 0, 14, and 28 of the first monthand every 28 days thereafter).32,33 Participants were postmenopausal women with locally advanced metastatic breast cancerfollowing progression or recurrence after endocrine therapy.In FINDER 1, the incidence of injection-site pain was 31.1%in the 250-mg group, 21.6% in the LD group, and 30.4% inthe 500-mg group.32 In FINDER 2, the safety profiles of thetheee regimens were similar.33 Injection-site pain was notedin all three treatment groups, with the lowest incidence inthe 500-mg group (250-mg/month group, 10.6%; LD group,10.0%; and 500-mg/month group, 6.5%).3334 oncology nurse advisor january/february 2013 www.OncologyNurseAdvisor.com
Patients with cancer are susceptibleto bruising or bleeding; vigilantfollow-up for factors that increasethis risk is needed.The CONFIRM study, a comparison trial of fulvestrant250 mg/month (one 5-mL injection of fulvestrant plus one5-mL injection of placebo) with 500 mg/month (two 5-mLinjections: 500 mg on days 0, 14, and 28 of month 1, thenevery 28 days thereafter) for advanced breast cancer pretreatedwith endocrine therapy, showed no significant differencesbetween the two doses in their safety profiles.30 Injection-sitereactions occurred in 13.6% and 13.4% of patients treated with500 mg/month and 250 mg/month, respectively.30Fulvestrant was evaluated as f irst-line treatment inthe Fulvestrant First-Line Study Comparing EndocrineTreatments (FIRST) study.34 Patients received fulvestrant500 mg/month (two 250-mg injections on days 0, 14, and28 of month 1, then every 28 days thereafter) or anastrozole1 mg/day as first-line therapy for advanced breast cancer.Of the 102 patients treated with the fulvestrant regimen,six patients reported 14 instances of injection-site pain, foran incidence of 1.3% of all injections and 5.9% of patients.34Fulvestrant (250-mg IM injection once monthly) was alsoexamined as first-line therapy compared with tamoxifen (20mg orally once daily) in a double-blind, randomized study.35Injection-site reactions were reported by 2.9% (nine of 310patients) receiving fulvestrant and 1.1% (three of 271 patients)receiving oral tamoxifen (placebo injection).35Overall, the incidence of injection-site pain with fulvestrant 500 mg/month appeared to be similar to that observedin prior clinical trials of the previously approved 250 mg/month regimen.31,34,36ADMINISTRATION BEST PRACTICESThe Z-track method, historically applied to IM injectionsof irritating medications, can be used for all IM injectionsto reduce pain and prevent dispersion of medication intosubcutaneous tissue1,3,13 (Figure 2). Other strategies for minimizing injection-site reactions are to alternate injection sitesand to apply warm or cold compresses to the injection site.29Fulvestrant should be stored between 2 C and 8 C, however,bringing it to room temperature prior to injection may aidthe injection process.37 Patients with cancer are susceptible tobruising or bleeding; therefore, vigilant follow-up for factorsthat may increase the risk of bruising or bleeding, such asthrombocytopenia or anticoagulant use, is needed.29A breast cancer nurse specialist has reported patientsoften comment that they do not feel the injection whenfulvestrant is administered with the Z-track method in thedorsogluteal site. Difficulty detecting the site postinjectionwas also reported, with no scarring after long-term (4 yearsor more) use.37 Best practices for administering fulvestrantsuch as depressing the plunger slowly and a slow injectionrate can make IM injections less painful, regardless of thedrug or injection volume.13,29,37,38 The high viscosity of fulvestrant serves to control its rate of administration, requiringapproximately 2 minutes per injection (see the online versionof this article for a summary of best practices).37Continued on page 36TABLE 1. Advantages and disadvantages of intramuscular injection sitesInjection siteMaximum InjectionVolume in Adult PatientsDeltoid0.5-2 mL3,14,16Dorsogluteal4 mL3,13Ventrogluteal2.5-5 mL3,12,13, 15,16 Free of nerves and blood vessels Narrower layer of fat of consistent thinnesscompared with dorsoglutealRectus femoris5 mL3 Can be used when other sites are contraindicated Patients can self-injectVastus lateralis5 mL3 Easily accessible No major blood vessels or nerve structuresAdvantagesDisadvantages Easily accessible Patient only exposes armNumber and volume of injections are limitedbecause of small injection-site area Major nerve and blood vessels present Slow absorption Thick layer of adipose tissueDiscomfort with injectionwww.OncologyNurseAdvisor.com january/february 2013 oncology nurse advisor 35
feature Large-volume IM injectionsZ-track injection techniqueABCFIGURE 2. Z-track injection technique prevents leakage into subcutaneous tissue and decreases the chance of local irritation. (A) Pull orpush the skin 2 to 3 cm away from the injection site with the nondominant hand. (B) Pierce the skin at 90 and depress the plunger slowly.If resistance occurs, pause then resume depressing the plunger. (C) Withdraw the needle, then release the skin.IN SUMMARYThe recent approval of fulvestrant 500 mg for the treatmentof HR metastatic breast cancer in postmenopausal womenwho received prior antiestrogen therapy highlights theincreased need for evidence-based IM-injection guidelineswith best practices for delivering large-volume (3 mL orgreater) IM injections. The practical recommendations discussed in this article are supported by current evidence fromthe literature, as well as from nursing experience within theclinical setting, and could be considered in future guidelinesfor large-volume IM injections.Evidence-based guidelines for large-volume IM injectionswill also depend on rigorous research. One area for futureresearch is to determine the optimal amount of time neededto administer large-volume injections, as medications inviscous solutions may take longer to inject. Optimal practices for patients of different weights and sizes should alsobe investigated because IM injections may be more difficultto administer in heavier patients and older patients mayhave low muscle mass or integrity. The potential benefits ofalternating injection sites, such as between the ventroglutealand dorsogluteal sites, in order to lessen patient discomfortshould be examined as well. Finally, future studies shouldassess the validity of clinical observations. For example,in our practice, we noted that occasionally patients havediscomfort upon sitting after a dorsogluteal IM injection.Two nurses administering fulvestrant simultaneously (ie,one nurse per injection per buttock) has been helpful forpatient comfort in our experience. Finally, we found thatmassaging the area during and after an IM injection helpsto prevent and relieve pain.With proper technique, appropriate patient education, andadequate follow-up, IM injections offer a safe and effectiveroute of medication delivery that supports treatment adherence and effective monitoring of adverse events. Furtherresearch and adherence to evidence-based best practiceswill undoubtedly enhance the efficacy and safety of thisadministration route as well as increase patient and clinician comfort. Acknowledgment The authors wish to thank Harleigh E. Willmott, PhD,and Stella Chow, PhD, of Scientific Connexions, Newtown, Pennsylvania,and Jennifer Steeber, PhD, and Antoinette Campo of SCI Scientificand Communications & Information, Parsippany, New Jersey, for theirmedical editorial assistance.Una Hopkins is administrative director at Dickstein Cancer Center inWhite Plains, New York. Claudia Arias is an oncology nurse at MemorialSloan Kettering Cancer Center in New York, New York. Financial supportfor medical editorial assistance was provided by AstraZeneca LP.REFERENCES1. Nicoll LH, Hesby A. Intramuscular injection: an integrative researchreview and guideline for evidence-based practice. Appl Nurs Res.2002;15(3):149-162.2 Shatsky M. Evidence for the use of intramuscular injections in outpatientpractice. Am Fam Physician. 2009;79(4):297-300.3. Rodger MA, King L. Drawing up and administering intramuscular injections: a review of the literature. J Adv Nurs. 2000;31(3):574-582.4. Intramuscular Injection. eNotes: Study Smarter Web site. rence/intramuscular-injection.Accessed January 16, 2013.36 oncology nurse advisor january/february 2013 www.OncologyNurseAdvisor.com
5. Fortaz [package insert]. Research Triangle Park, NC: GlaxoSmithKline; 2010.6. Zinacef [package insert]. Research Triangle Park, NC: GlaxoSmithKline;2009.24. Eker HE, Cok OY, Aribogan A. A treatment option for post-injectionsciatic neuropathy: transsacral block with methylprednisolone. PainPhysician. 2010;13(5):451-456.7. Invanz [package insert]. Whitehouse Station, NJ: Merck & Co, Inc; 2011.8. Bicillin L-A [package insert]. Bristol, TN: King Pharmaceuticals; 2009.9. Faslodex [package insert]. Wilmington, DE: AstraZenecaPharmaceuticals LP; 2012.25. Pandian JD, Bose S, Daniel V, et al. Nerve injuries following intramuscularinjections: a clinical and neurophysiological study from Northwest India.J Peripher Nerv Syst. 2006;11(2):165-171.26. Boyd A, Mares J, DeFord L, Yao J. Gluteal intramuscular injections:10. Clinical Practice Project Group. Guidelines for administration of anintramuscular injection. Cheshire Ireland Web site. df. Accessed January 16, 2013.11. Kroger AT, Atkinson WL, Marcuse EK, Pickering LK; Advisory Committeeon Immunization Practices (ACIP) Centers for Disease Control andPrevention (CDC). General recommendations on immunization: recommendations of the Advisory Committee on Immunization Practices(ACIP). MMWR Recomm Rep. 2006;55(RR-15):1-48.12. Cambridgeshire and Peterborough NHS. Guidelines for Administrationof
However, few evidence-based guidelines for IM injections are available, and discrepancies within nursing textbooks have been noted. 10-13 In addition, current guidelines do not address administration of large-volume injections. The dorsogluteal site for IM injections is the one nurses have the most experience using, as this is what is tradi-File Size: 256KBPage Count: 6Explore furtherLarge-volume IM injections: A review of best practices .www.oncologynurseadvisor.comInjection Safety CDCwww.cdc.govGUIDELINES ON THE ADMINISTRATION OF INTRAMUSCULAR www.olchc.ieSECTION 20: PEDIATRICS: Medication: Intramuscular .www.vnhcsb.orgIntramuscular injection: Locations and administrationwww.medicalnewstoday.comRecommended to you b
make money Raise money for salaries or clinic by activities that do not harm patients nor waste medications. Outline: How to give injections safely Eliminate unnecessary injections Use sterile injection equipment and sharps Prepare and give injections without causing
Z-track injections in oil, narcotics and sedatives; typical volume is 1–4 ml. It is best used when large-volume intramuscular injections are required and for injections in the elderly, non-ambulant and emaciated patient as it provides
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Forelimb Injections Elbow Injections Common Indications: Osteoarthritis Recommended Needle: 22 gauge, 1.5” Syringe for Aspirating Synovial Fluid: 5 or 6 mL Landmark for Blind Injection: Medial Epicondyle Process Key Guidelines Injection Volume Guidelines Size of Dog Total Injection Volume
Intramuscular (IM) Advantages: Larger volume than SC can be given by IM. They may be easier to administer than IV injections. A depot or sustained release effect is possible with IM injections, e.g. procaine penicillin. Disadvantages: Trained personnel required for injections. The site of
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Trigger Point Injections Definitions Trigger point injections are defined as an injection of a local anesthetic with or without the addition of a corticosteroid into clinically identified myofascial trigger points. Myofascial trigger point is defined as a discrete, focal, hyperirritable spot found
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